Provider Demographics
NPI:1104136399
Name:DESTACKELBERG, JARED A (PA)
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:A
Last Name:DESTACKELBERG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1901 SE 18TH AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-8215
Mailing Address - Country:US
Mailing Address - Phone:352-622-3360
Mailing Address - Fax:352-671-3269
Practice Address - Street 1:1901 SE 18TH AVE
Practice Address - Street 2:STE 101
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-8215
Practice Address - Country:US
Practice Address - Phone:352-622-3360
Practice Address - Fax:352-671-3269
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPAT 9105672363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant